- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,704.99 / $1,704.99 / $2,131.23
| Professional | | $1,704.99 | $1,704.99 | $2,131.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,223.16 / $1,612.62 / $2,895.18
| Facility | | $1,223.16 | $1,612.62 | $2,895.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,497.00 / $3,816.68 / $3,816.68
| Professional | | $1,497.00 | $3,816.68 | $3,816.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,497.00 / $1,497.00 / $1,497.00
| Facility | | $1,497.00 | $1,497.00 | $1,497.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.20 / $1,524.80 / $1,882.27
| Professional | | $1,291.20 | $1,524.80 | $1,882.27 |